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CHASE�� <br />w® Merchant Services • 4 Northeastern Boulevard, Salem, NH 03079-1952 • www.chasepaymentech.com <br />,fla, — 1 CrPhone: (603) 896-6000 • Fax: (603) 896-8715 • Merchant_Services@ChasePaymentech.com <br />Section C: FINAL DESTINATION SANK <br />Account Where Your Funds are Deposited <br />C1 Swift Code: (8 to 11 bytes) <br />C2 Sort Code: (Required in Great Britain Only) <br />C3 [BAN/Bank Account# <br />Company Name: (As appears on Bank account) <br />Financial Institution Name: <br />City: State/Province: Postal Code: Country: <br />Special Wire Instructions: (60 bytes) <br />Section D INTERMEDIARY/CLEARING BANK ACCOUNT INFORMATION <br />Note: For Int'l Deposits ggoing through J.P. Morgan Chase in London, Intermediary is not required Complete Section "C' only <br />D1 <br />Swift Code: (8 to 11 bytes) <br />D2 Sort Code: (Required in Great Britain Only) <br />D3 Wire Transfer: (USA Only) <br />(Routing #) <br />D4 Financial Institution Name: <br />City: State/Province: Postal Code/Zip: <br />Country: <br />Special Wire Instructions: (60 bytes) <br />Section E Signature <br />"On behalf of City of Santa Ana I, Francisco Gutierrez <br />represent and warrant <br />(Merchant Legal Name) (Print Name) <br />that I have the authority to add banking information and I verify that the above banking information is accurate and should be used to <br />transfer funds accordingly." <br />A__ _ _ _ Finance Director <br />ti t ,z,.t I z o $ s- <br />AutForized Si nature* Title <br />Date <br />(*Must be signed by Executive or Financial Contact) <br />Note: In order to process this request, please attach an original voided check (starter check or bank <br />statements not applicable) or a bank letter of verification. <br />----------------------------------------------------------------------------------------------------------------------- <br />ATTACH VOIDED CHECK HERE <br />--------------------------------------------------------------------------------------------------- <br />Revl1/18/10 9 New Division/cboo <br />